cost-effectiveness of the hibalance training program for

Joseph, C. et al. (2018). Cost-effectiveness of the HiBalance training program for elderly with

Parkinson’s disease: analysis of data from a randomized controlled trial.

Clinical Rehabilitation, 2018: 1-11.

http://dx.doi.org/10.1177/0269215518800832

University of the Western Cape Research Repository [email protected]

Cost-effectiveness of the HiBalance training program for elderly

with Parkinson’s disease: analysis of data from a randomized

controlled trial

Conran Joseph, Nina Brodin, Breiffni Leavy, Maria Hagströmer, Niklas Löfgren and Erika

Franzén

Abstract

Objective: To determine the cost-effectiveness of the HiBalance training program for

managing Parkinson’s disease (PD)-related balance and gait disorders.

Design: Cost comparison design following the randomized controlled trial comparing a

novel balance training intervention with care as usual.

Subjects: A total of 100 participants with mild–moderate PD were randomized to either the

intervention (n = 51) or the control group (n = 49).

Intervention: A 10-week (three times per week), group-based, progressive balance

training program, led by two physical therapists.

Main outcomes: All program costs were collected for both groups. Cost-utility was

evaluated using quality-adjusted life years (QALYs) and cost-effectiveness measures were

the Mini Balance Evaluation Systems Test (Mini-BESTest; assessing balance performance)

and gait velocity. Incremental cost-effectiveness ratios were calculated and a probabilistic

sensitivity analysis was conducted.

Results: The between-group difference in QALYs was 0.043 (95% confidence interval (CI):

0.011–0.075), favoring the intervention group. Between-group differences in balance

performance and gait velocity were 2.16 points (95% CI: 1.19–3.13) and 8.2 cm/second

(95% CI: 2.9–13.6), respectively, favoring the intervention group. The mean cost per

participant in the intervention group was 16,222 SEK (€1649) compared to 2696 SEK

(€274) for controls. The estimated incremental cost-effectiveness ratios were 314,558 SEK

(€31,969) for an additional QALY, 6262 SEK (€631) for one point improvement in balance

performance, and 1650 SEK (€166) for 1 cm/second increase in gait velocity. Sensitivity

analyses indicated a high probability (85%) of program success.

Conclusion: In terms of QALYs, the HiBalance program demonstrated a high

probability of cost-effectiveness in the short-term perspective when considering the

willingness-to-pay thresholds used in Europe.

Introduction

Impaired balance is a major issue in people with Parkinson’s disease (PD). The lack of

sufficient balance performance predisposes people with PD to potentially injurious falls

http://dx.doi.org/10.1177/0269215518800832

mailto:[email protected]

2

which, in turn, compromise one’s quality of life, livelihood, and functioning.1–3 A

specific training regime, the HiBalance training program consisting of highly challenging

dynamic balance exercises, has been developed in Sweden.4,5 The program was found to

be effective in improving balance and gait velocity, which exceeded the minimal clinically

important difference of 0.05 m/second (for gait velocity), as commonly used in elderly

and persons with PD.6,7 Given the promising findings in the earlier randomized

controlled trial,8 the need exists to evaluate the cost-effectiveness of the HiBalance

program for consideration by health-care decision-makers who are responsible for

strengthening healthcare systems, especially in rehabilitation.

In an era with limited resources for health services, it is important to evaluate the economic

aspects of interventions, with the aim of selecting the option associated with the best value.

The HiBalance program was developed in a time when a distinct need for rehabilitation

interventions targeting motor symptoms existed, and was found to be effective as well as

highly appreciated by participants.8,9 With the next step directed toward the

implementation of the program, its cost-effectiveness needs to be established. Therefore, the

aim of this cost comparison study was to determine the cost-utility, accounting for cost-

effectiveness, of the HiBalance training program in terms of changes in health-related quality

of life as well as balance performance and gait velocity over a 10-week intervention period.

Methods

Design and participants

An economic evaluation of the HiBalance program was carried out whereby costs and the

associated outcomes of the HiBalance program versus regular care were compared. The

effects of the HiBalance program were previously examined in a single-blinded,

randomized, controlled trial which recruited participants between January 2012 and July

2013.8 In total, 146 participants were recruited through advertisements in local

newspapers, Karolinska University Hospital, and outpatient neurological clinics in

Stockholm County, Sweden. The Regional Ethical Board in Stockholm provided ethical

clearance (dnr: 2009/819-32, 2010/1472-32, 2012/1829-32), and the study was

subsequently registered in ClinicalTrials.gov (trial registration no. NCT01417598).

To be eligible for participation, clients had to present with a clinical diagnosis of idiopathic

PD, have a Hoehn and Yahr10 score of 2 or 3, be 60 years or above, independently

ambulate indoors without a walking aid, and be on a stable dose of anti-Parkinson’s

medication for at least three weeks. The exclusion criteria were as follows: (1) impaired

mental function which was confirmed by a score less than 24 on the Mini-Mental State

Examination11 and (2) the presence of other medical conditions which may influence the

main study outcomes.

https://repository.uwc.ac.za/

3

Interventions

The HiBalance training program was developed to specifically target balance impairments in

persons with PD, relating to the following four components: (1) sensory integration, (2)

anticipatory postural adjustments, (3) motor agility, and (4) stability limits. The 10-week

(three times per week) program was group-based, consisted of 4–7 participants, and

facilitated by two trained physiotherapists at all sessions. Each session lasted 60 minutes

and consisted of a 5-minute warm-up, 50-minute highly challenging balance exercises, and a

5-minute cool-down period at the end. The training program contained exercises that were

individualized to the ability of participants. Importantly, no fixed regime of predetermined

exercises was used; instead, motor learning principles, including specificity, progressive

overload, and variation, were adopted for the application and adaptation of exercises to

suit participants’ abilities. To address specificity, exercises were linked to the four balance

components, and variation was achieved by integrating and combining different balance

components within a single session or activity as the program progressed through the

three distinct stages (also called Blocks A, B, and C). In addition, dual-tasking, either

cognitive (e.g. counting and remembering items) or motor (e.g. carrying or manipulating

objects), was gradually integrated to aid progression. Progressive overload was further

enhanced by increasing the complexity of exercises once participants made fewer to no errors

by, for example, increasing surface unevenness to challenge sensory integration and

increasing movement amplitude and velocity to challenge anticipatory postural

adjustments. Further details of the HiBalance program can be found in previous

publications.4,5,8

Participants randomized into the control group received usual care from their healthcare

service providers. Participants in the control group were allowed to enroll in and/or

continue with their organized health-enhancing activities, such as training by oneself or

participating in exercise classes. All participants serving as controls were offered the

HiBalance program at the end of the study period.

Outcomes and costs

Participants, in both the intervention and control groups, were evaluated at baseline and

after the intervention which lasted 10 weeks. Cost-utility was assessed in terms of gains in

quality-adjusted life years (QALYs). The Short Form-36 version 1 was used to evaluate

generic quality of life. The Short Form-36 raw data were transformed to a Short Form-

6D utility index score. The Short Form-6D utility scores come with a set of preference

weights obtained from a sample of the general population in the United Kingdom, using

the standard gamble valuation technique.12 Values were given by the reference

population to a selection of health states from which a model had been developed to

predict all the health states described by the Short Form-6D.13 The score ranges from

zero to one, with zero being dead and closer to one suggesting “almost perfect health.”

Cost-effectiveness outcomes were balance performance and gait velocity. Balance

performance was assessed using the Mini Balance Evaluation Systems Test (Mini-


4

BESTest). It assesses the underlying subsystems of balance performance (anticipatory

postural adjustment, postural responses, sensory integration, and dynamic gait) on a three-

level ordinal scale. The total score ranges from 0 to 28, with a higher score reflecting better

balance performance.14 Gait velocity was assessed using a 9-meter electronic walkway

(GAITRite; CIR Systems Inc., Clifton, NJ, USA) and expressed in cm/second.

A cost comparison approach was implemented to study the cost-effectiveness of the training

program versus care as usual. Although not exhaustive, direct and indirect, as well as

social, costs were considered and formed part of the estimation of costs for each

intervention. Intervention-related costs were retrospectively collected, and for that reason

an annual inflation rate of 1% was added to present what the HiBalance intervention would

cost today. Inflation in Sweden has remained low over the last five years, with a year-on-

year rate ranging from −0.31 to 1.74 (http://www.inflation.eu/inflation-rates/cpi-

inflation.aspx).

Costs related to both groups included (1) education of physiotherapists for assessments, (2)

participants’ and therapists’ costs during assessments, and (3) equipment and facilities used

during assessments. Additional intervention-related costs included 30 hours of HiBalance

training per person, that is, trainers’ salary costs, delivered three times weekly for 10

weeks, costs for hiring the venue, and participants’ time costs (30 hours). An additional 30

hours (1 hour per session) was added to the trainers’ costs for preparation and planning, an

important aspect of the program for ensuring individualized and progressive balance

exercises, and documentation following the training session. Furthermore, an additional 30

hours was added to participants’ time to account for traveling to and from training venue.

Since cost data were retrospectively collected, we were unable to precisely estimate trainers’

and participants’ time costs. Our estimate therefore represents the mean hourly wage of

physiotherapists who delivered the education and training (2012/2013) in this study.

Participants’ costs were similarly estimated by adopting the mean hourly wage of retired

people in Sweden during the year 2012/2013. It is important to note that the total cost

estimate presented in this study does not include costs incurred by additional healthcare

(such as medications) and other health-enhancing leisure activities.

Statistical analysis

Data were analyzed in Stata (STATA Corp, College Station, TX, USA) version 13, where an

intention-to-treat approach was followed. For the description of baseline data between

groups, the chi-square test was used for nominal data and independent-samples t-test for

continuous data. Levene’s test, in combination with visual inspection, was used to

determine the normality of outcomes used in this study. Since all outcomes fulfilled these

criteria, multivariate linear regression analysis was used to estimate the mean (95%

confidence interval (CI)) between-group differences for QALYs, balance performance, and

gait speed by controlling for baseline utility/score, group allocation, and disease severity.


http://www.inflation.eu/inflation-rates/cpi-inflation.aspx



5

Cost-effectiveness was calculated by considering the intervention costs per participant in

relation to the net effect seen in the Short Form-6D utility score, balance performance,

and gait velocity. The comparator was “usual care” as previously described. Incremental

cost-effectiveness ratios ((costintervention – costcontrol)/(effectintervention – effect-

control)) were calculated to determine the costs associated with every unit increase in the

selected study outcomes (see Table 4). A probabilistic sensitivity analysis was performed,

with cost-effectiveness acceptability curves produced, to test for uncertainty around

incremental cost-effectiveness ratios. The effectiveness and utility estimations have been

replicated on 10,000 non-parametric bootstrap samples, stratified by treatment group.

Based on the set of 10,000 estimates from the bootstrap procedure, cost-effectiveness

acceptability curves have been produced against a range of values representing society’s

willingness to pay for such health-enhancing interventions. The cost-effectiveness analysis

was performed using R (RStudio v 1.1.419). The boot function was used for the bootstrap

sampling, and the icea function of the hesim package was used to produce results for the

cost-effectiveness acceptability curves.

Results

Participants’ characteristics

A total of 100 participants were enrolled in this study, with 51 and 49 allocated to the

intervention and control groups, respectively (Figure 1). As shown in Table 1, no

significant differences were present between the groups with respect to demographics,

anthropometric measures, clinical features, or baseline utility and effectiveness

outcomes.

Effects of the intervention

Concerning the utility outcome, a significant difference, according to the transformed Short

Form-6D utility score, was noted in the intervention group following the treatment period

but not in the control group (Table 2). The estimated between-group difference in utility

for the period under study was 0.043 QALYs (95% CI: 0.011–0.075), benefiting the

intervention group. Furthermore, a significant improvement of 2.16 points (95% CI:

1.18–3.12) was observed for balance performance in the intervention group, compared

with controls, following the HiBalance training.


6

Similarly, a significant improvement of 8.2 cm/ second (95% CI: 3.0–13.6) in gait

velocity was observed when comparing the mean difference estimate between groups,

again favoring the intervention group.

Intervention costs

The total cost for the intervention was 959,413 SEK (€97,535), with a larger proportion of the

spending directed toward the intervention group (86%).


7

As shown in Table 3, the estimated mean difference in total costs between the

intervention and control groups was 13,526 SEK (€1375) per participant.

Cost-effectiveness analysis of the intervention

As shown in Table 4, the incremental cost associated with an improvement in 1 QALY is

estimated at 314,558 SEK (€31,712). The incremental cost-effectiveness ratio for balance

performance was 6262 SEK (€631; one unit increase in the Mini-BESTest score per

patient in the intervention group). Gait velocity improved by approximately 8 cm in the

intervention group, resulting in a corresponding incremental cost-effectiveness ratio of

1650 SEK (€166) per unit (i.e. 1 cm).

Uncertainty analysis

The cost-effectiveness acceptability curves (Figures 2–4) show the robustness of the model

regarding the uncertainty estimation of the outcomes for each group. These cost-

effectiveness acceptability curves included the association between the values of the ceiling

ratio (e.g. willingness to pay for a unit of QALY gained) and the probability of favoring

the intervention group. Concerning the uncertainty around the QALY outcome, the

results showed that the HiBalance intervention has an 85% probability of being cost-

effective given a willingness to pay of 500,000 SEK per QALY. The results concerning balance


8

performance indicate that the intervention has 70% and 85% probability of producing a

sufficiently large treatment effect if the payer is willing to pay 7000 and 8000 SEK,

respectively, for one unit increase. Furthermore, the intervention has 72% and 86%

probability of producing a sufficiently large treatment effect if the payer is willing to pay

2000 and 2500 SEK, respectively, for every centimeter/second improvement in gait

velocity.


9


10

Discussion

This study assessed the cost-utility, as well as cost-effectiveness, of a novel balance training

program for persons with mild–moderate PD enrolled in a randomized controlled trial. The

analysis revealed that the HiBalance intervention is good value for money, according to

gains made in QALYs, in the short-term perspective. It further shows that improvements in

balance performance and gait velocity are achievable at a reasonable cost, albeit more

expensive than usual care.

A decision on an intervention’s cost-effectiveness depends upon gains made in QALYs, and the

willingness of healthcare decision makers/society to pay for them. We found a significant

difference in QALY between groups, favoring those receiving the intervention. In absolute

terms, this 10-week program added, on average, an additional 15 days of perfect health to

the intervention group, while 1 QALY would cost 314,558 SEK (€31,712). Despite the use of

best-evidence approaches, no formal monetary value for a QALY exists in Sweden.

However, a published review of the Swedish government agency responsible for deciding

whether drug interventions are covered by its scheme found a value of 1,220,000 SEK to

be the highest cost per QALY approved for reimbursements.15 It further found that at a cost

per QALY of 702,000 SEK for non-severe diseases and 988,000 SEK for severe diseases, the

likelihood of approval was estimated to be 50/50.

The preservation of functioning in persons with PD remains a top priority. To realize this,

physiotherapy as well as occupational therapy is an essential requirement.16 As highlighted

by Tomlinson et al.,7 very few studies in the rehabilitation arena incorporate economic

evaluations alongside pragmatic randomized controlled trials, which, in turn, hampers the

identification of cost-effective interventions targeting disabling symptoms. Although not

similar in intervention, one cost-effectiveness study investigating a physical activity

intervention among elderly found similar effects on QALY as in this study, albeit slightly more

costly.17 It should be noted that our study included fewer costs, which may have resulted


11

in the different thresholds reached in these studies. Another systematic review also

reported overall cost-effectiveness of brief physical activity interventions on QALY,18

while exercise and other physiotherapy-related modalities were also found to be cost-

effective in the management of osteoarthritis, considering a willingness-to-pay threshold

of approximately €50,000.19 Specific to this study, we found that the HiBalance

intervention had a high probability (85%) of being cost-effective against a willingness-to-pay

threshold of 500,000 SEK (€50,000).

As observed in this study, disease-relevant outcomes improved significantly over the course of

the intervention period. First, balance performance increased, on average, by two units

according to the Mini-BESTest. Although the mean estimate change in balance performance

did not meet the threshold for minimal clinically important difference,20 it should however

be considered in conjunction with gait velocity which improved beyond its minimally

clinically important difference of 5 cm/second often used in PD.7 This balance training

program offered similar effects on balance performance and gait velocity as other

comparable physiotherapy interventions previously investigated in randomized controlled

trials.21,22 Maintenance and improvement of gait velocity has been established as an

important target among elderly populations, mainly due to its association with

compromised quality-of-life states23 and mortality, specifically that of cardiovascular

origin.24,25 To our knowledge, no published studies investigated the benefits of balance

training in relation to its associated costs. Our reported costs per unit increase in balance

performance and gait velocity demonstrate how significant changes in health outcomes

represent only a small fraction of annual patient healthcare costs.26 Sensitivity analysis of

this program’s cost-effectiveness revealed a high probability of success albeit at a higher

cost than usual care, where the latter typically includes no structured programs. It is

however difficult to interpret the willingness-to-pay thresholds for balance and gait velocity

improvements in our study, since no other published health economic evaluations in the

Parkinson’s rehabilitation field are available to serve as a comparator.

Not all interventions are equally effective, let alone cost-effective. A range of studies

suggest the use of intensive and challenging exercises in promoting and maintaining

functioning, specifically gait speed and motor strength, above usual care.27,28 The

HiBalance training program under investigation in this study is one of the few effective

physiotherapy interventions directed at targeting functional decline among persons with

PD. It should be considered for wider adoption considering its clear theoretical

underpinnings, safety, and newly established cost-effectiveness. Such information is

required for successful uptake of interventions in practice.29

This study presents with several limitations which require consideration. The retrospective

approach to cost estimation prevented the actualization of exact costs of some expenses, for

example, participants’time and travel costs. Furthermore, certain costs, specifically related to

medication and additional healthcare/hospitalizations, as well as sick leave benefits, were


12

omitted since the necessary permissions were not in place. These omissions have, most

likely, affected total cost estimates and the cost per utility, which might influence the

decision making around society’s willingness to pay for this intervention. Furthermore,

the use of United Kingdom’s preference-based weights for deriving at the Short Form-6D

utility scores for our cohort can be seen as another limitation. There is a risk that Swedes

may hold different health state preferences than citizens from the United Kingdom. Finally,

an obvious limitation of the sensitivity analysis was that intervention costs were fixed for the

two groups due to the research paradigm being a controlled trial. To promote wider access of

this effective rehabilitation intervention, future studies should use Swedish tariffs for utility

measures and include all related healthcare costs during and after the intervention in order

to convince healthcare decision-makers about the necessity of these health-enhancing

interventions.

Overall, the results demonstrated that the HiBalance intervention is likely to induce

better health states as well as balance performance and gait speed than usual care but at

a higher cost. This intervention appears promising in terms of both delivering desired

effects and its cost. However, prior to the wider implementation of the HiBalance

training program, a more comprehensive assessment of costs, from a full societal

perspective, along with a longer follow-up period of costs and outcomes collection, should

be carried out in order to affirm its cost-utility and cost-effectiveness.


13

Acknowledgements

We would like to thank all people with PD who have participated in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,

authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research,

authorship, and/or publication of this article: We are grateful for the financial support from

the Swedish Research Council (2016-01965), the Swedish Research council for Health,

Working life and Welfare (FORTE; 2014-4764), and “Vårdalstiftelsen” (2014-79). These

funding agencies had no role in the design, collection, and interpretation of data and

writing of the manuscript.

ORCID iDs

Conran Joseph https://orcid.org/0000-0002-3121-2685

Erika Franzén https://orcid.org/0000-0001-5520-544X


https://orcid.org/0000-0002-3121-2685

https://orcid.org/0000-0001-5520-544X

14

References

1. Kerr GK, Worringham CJ, Cole MH, et al. Predictors of future falls in Parkinson

disease. Neurology 2010; 75(2): 116–124.

2. Kim SD, Allen NE, Canning CG, et al. Postural instability in patients with

Parkinson’s disease. Epidemiology, pathophysiology and management. CNS Drugs

2013; 27(2): 97–112.

3. Pickering RM, Grimbergen YA, Rigney U, et al. A meta-analysis of six prospective

studies of falling in Parkinson’s disease. Mov Disord 2007; 22(13): 1892–1900.

4. Conradsson D, Lofgren N, Stahle A, et al. A novel conceptual framework for balance

training in Parkinson’s disease-study protocol for a randomised controlled trial. BMC

Neurol 2012; 12(111): 1471–2377.

5. Conradsson D, Lofgren N, Stahle A, et al. Is highly challenging and progressive

balance training feasible in older adults with Parkinson’s disease? Arch Phys Med

Rehabil 2014; 95(5): 1000–1003.

6. Perera S, Mody SH, Woodman RC, et al. Meaningful change and responsiveness in

common physical performance measures in older adults. J Am Geriatr Soc 2006;

54(5): 743–749.

7. Tomlinson CL, Patel S, Meek C, et al. Physiotherapy intervention in Parkinson’s

disease: systematic review and meta-analysis. BMJ Brit Med J 2012; 345: e5004.

8. Conradsson D, Lofgren N, Nero H, et al. The effects of highly challenging balance

training in elderly with Parkinson’s disease: a randomized controlled trial.

Neurorehabil Neural Repair 2015; 29(9): 827–836.

9. Leavy B, Roaldsen KS, Nylund K, et al. “Pushing the limits”: rethinking motor and

cognitive resources after a highly challenging balance training program for Parkinson

disease. Phys Ther 2017; 97: 81–89.

10. Hoehn MM and Yahr MD. Parkinsonism: onset, progression and mortality.

Neurology 1967; 17(5): 427–442.

11. Folstein MF, Folstein SE and McHugh PR. “Mini-mental state.” A practical method

for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;

12(3): 189–198.

12. Brazier J, Usherwood T, Harper R, et al. Deriving a preference-based single index

from the UK SF-36 Health Survey. J Clin Epidemiol 1998; 51(11): 1115–1128.

13. Brazier JE and Roberts J. The estimation of a preference-based measure of health

from the SF-12. Med Care 2004; 42(9): 851–859.

14. Franchignoni F, Horak F, Godi M, et al. Using psychometric techniques to improve

the Balance Evaluation Systems Test: the mini-BESTest. J Rehabil Med 2010;

42(4): 323–331.

15. Svensson M, Nilsson FO and Arnberg K. Reimbursement decisions for

pharmaceuticals in Sweden: the impact of disease severity and cost effectiveness.

Pharmacoeconomics 2015; 33(11): 1229–1236.

16. Fox SH, Katzenschlager R, Lim SY, et al. The Movement Disorder Society evidence-

based medicine review update: treatments for the motor symptoms of Parkinson’s

disease. Mov Disord 2011; 26(suppl. 3): S2–S41.


15

17. Groessl EJ, Kaplan RM, Castro Sweet CM, et al. Cost-effectiveness of the LIFE

physical activity intervention for older adults at increased risk for mobility disability.

J Gerontol A Biol Sci Med Sci 2016; 71(5): 656–662.

18. GC V, Wilson EC, Suhrcke M, et al. Are brief interventions to increase physical

activity cost-effective? A systematic review. Br J Sports Med 2016; 50: 408–417.

19. Pinto D, Robertson MC, Hansen P, et al. Cost-effectiveness of nonpharmacologic,

nonsurgical interventions for hip and/or knee osteoarthritis: systematic review. Value

Health 2012; 15(1): 1–12.

20. Godi M, Franchignoni F, Caligari M, et al. Comparison of reliability, validity, and

responsiveness of the mini-BESTest and Berg Balance Scale in patients with balance

disorders. Phys Ther 2013; 93(2): 158–167.

21. Tomlinson CL, Herd CP, Clarke CE, et al. Physiotherapy for Parkinson’s disease: a

comparison of techniques. Cochrane Database Syst Rev 2014; 6: CD002815.

22. Sparrow D, DeAngelis TR, Hendron K, et al. Highly challenging balance program

reduces fall rate in Parkinson disease. J Neurol Phys Ther 2016; 40(1): 24–30.

23. Herman T, Giladi N, Gruendlinger L, et al. Six weeks of intensive treadmill training

improves gait and quality of life in patients with Parkinson’s disease: a pilot study.

Arch Phys Med Rehabil 2007; 88(9): 1154–1158.

24. Dumurgier J, Elbaz A, Ducimetière P, et al. Slow walking speed and cardiovascular

death in well functioning older adults: prospective cohort study. BMJ 2009; 339:

b4460.

25. Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA

2011; 305(1): 50–58.

26. Kowal SL, Dall TM, Chakrabarti R, et al. The current and projected economic burden

of Parkinson’s disease in the United States. Mov Disord 2013; 28(3): 311–318.

27. Shulman LM, Katzel LI, Ivey FM, et al. Randomized clinical trial of 3 types of physical

exercise for patients with Parkinson disease. JAMA Neurol 2013; 70(2): 183–190.

28. Frazzitta G, Balbi P, Maestri R, et al. The beneficial role of intensive exercise on

Parkinson disease progression. Am J Phys Med Rehabil 2013; 92(6): 523–532.

29. Allen NE, Sherrington C, Suriyarachchi GD, et al. Exercise and motor training in

people with Parkinson’s disease: a systematic review of participant characteristics,

intervention delivery, retention rates, adherence, and adverse events in clinical trials.

Parkinson’s Dis 2012; 2012: 854328.


cost-effectiveness of the hibalance training program for

Documents